GERIATRI PARADIGM

Geriatrics is the practice of care for frail older people. The epitome of geriatrics is treating multiple interactive problems that cross domains. In essence, geriatrics represents the intersection of chronic disease care and gerontology. Clinicians caring for older persons need to understand that diseases present differently in older persons, and their management is complicated by the presence of other factors. Older people take more medications, and hence are at greater risk of drug interactions. Older people may face problems in other sectors of their lives, such as their social roles, their economic status, their cognition, and their affect, which complicates treatment for specific health problems.

May be as hard to detect as a new peak among the Alps. The second relevant concept is based on the changes associated with aging. In general, age-related physiological changes are most evident in dynamic measures. Older people do not react to stress as well as their younger counterparts. Most of the manifestations of disease, what we call signs and symptoms, are usually not the effects of the disease per se, but the body’s reaction to the stress produced  by the disease. Little wonder, then, that older people would not show the classic symptoms of a disease, but instead some muted or general response. Whereas a younger person having a heart attack might complain about chest pain, an older person might present with confusion. This same symptom could be caused by pneumonia or a drug reaction. Thus, diagnosing disease in older people is often a much more difficult feat than with younger patients.

Diagnosis is hindered still further by communication problems created by problems with vision, hearing, or dementia. On top of these communication problems, older people often suffer from multiple diseases, making it harder to distinguish the onset or change of a given symptom. The basic technology of geriatrics is the comprehensive geriatric assessment (CGA). Experience has taught that exposing frail older persons to such an evaluation and then returning them to the same care environment did not sustain the effects. Gradually the concept of geriatric evaluation and management (GEM) evolved, which involved treating the patient for as long as needed to implement and sustain the necessary changes in the regimen. Few other approaches to care have been studied as thoroughly as CGA and GEM. Unfortunately, the results have provided a confusing and often contradictory story. Although meta-analyses imply that CGA is effective, the pattern is not consistent. Table 3 summarizes the results of several inpatient CGA/GEM randomized trials. Table 4 offers a comparable summary of outpatient studies. One of the largest and most recent studies was a multisite trial that involved both types of care. Although it was carefully targeted to patients who were deemed likely to benefit, it found scant effects. By contrast, a study that involved a simple home visit by a nurse practitioner to unselected older persons living at home yielded potent benefits, as did a preventive assessment by occupational therapists.